Translational Issues in Psychological Science 2016 American Psychological Association

2016, Vol. 2, No. 4, 395 407 2332-2136/16/$12.00 http://dx.doi.org/10.1037/tps0000090

Rumination and Mindfulness Related to Multiple Types of

Trauma Exposure

Sungjin Im Victoria M. Follette

University of Nevada, Reno Florida Institute of Technology

Prior research has indicated that exposure to multiple types of trauma is associated with
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increased trauma symptomatology and other psychological problems (Follette, Po-

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lusny, Bechtle, & Naugle, 1996). However, research is limited regarding mechanisms
that underlie this relationship. Rumination has been proposed to explain the link
between trauma exposure and later symptoms (Michael, Halligan, Clark, & Ehlers,
2007). Moreover, related findings suggest that rumination can be reduced by mindful-
ness practice that enhances the present-moment focus of attention and a nonjudgmental
stance toward ones inner experiences (Kearney, McDermott, Malte, Martinez, &
Simpson, 2012). The present study tested whether exposure to multiple types of trauma
is positively associated with trauma-related symptomatology and psychological dis-
tress. We also tested 2 mediating models examining the role of rumination and
mindfulness in relation to trauma. In a self-report study, nontreatment-seeking college
students (N 157) rated the number of types of trauma exposure, rumination,
mindfulness, trauma symptoms, and psychological distress they had experienced.
Results showed that having experienced multiple types of trauma was associated with
more severe trauma symptomatology and psychological distress. Bootstrap analyses for
indirect effects indicated that rumination mediated the effect of the number of trauma
types on trauma symptomatology and psychological distress. In addition, rumination
mediated the inverse relationship between mindfulness and trauma outcomes. Despite
several limitations, the findings of the current study highlight the importance of
providing treatment that addresses rumination and mindfulness.

Keywords: trauma, rumination, mindfulness, PTSD, psychological distress

In the United States, 56 90% of individuals
experience at least one traumatic event, such as
a life-threatening accident, unwanted sexual ex-
perience, or a violent crime during their life-
times (Breslau et al., 1998; Kessler, Sonnega,
Bromet, Hughes, & Nelson, 1995). Exposure to
traumatic events has been associated with psy-
chological disorders, such as posttraumatic
stress disorder (PTSD), depression, substance-
Editors Note. Mary Beth Kenkel served as the action
editor for this article.MBK
Sungjin Im, Department of Psychology, University of
Nevada, Reno; Victoria M. Follette, School of Psychology,
Florida Institute of Technology.
Correspondence concerning this article should be ad-
dressed to Sungjin Im, Department of Psychology, Univer-
sity of Nevada, Reno, 1664 North Virginia Street, Reno, NV
89523. E-mail: im.sungjin@yahoo.com
395
use disorders, anxiety disorders, and suicidal
ideation (Galatzer-Levy, Nickerson, Litz, &
Marmar, 2013; Kessler et al., 1995). Trauma
has also been shown to negatively affect a range
of life domains, such as physical health (e.g.,
somatic complaints and disability), interper-
sonal relationships (e.g., reduced social sup-
port), and quality of life (Friedman & Schnurr,
1995; Olatunji, Cisler, & Tolin, 2007). Despite
the negative effects of traumatic experiences,
many individuals are resilient following expo-
sure to potentially traumatic events (Bonanno,
2004). More research is needed to understand
the underlying mechanisms between trauma ex-
posure and trauma symptomatology, particu-
larly in those with exposure to multiple trauma
types. In this study, we produced empirical find-
ings using a mediational model to conceptualize
the relationships among the multiple types of
trauma, rumination, mindfulness, and trauma-
 396 IM AND FOLLETTE
related symptoms that participants had experi-
enced.
Overview of a Conceptual Model
Many people report psychological distress
and temporary disruptions in functioning fol-
lowing exposure to traumatic experiences (Bo-
nanno, 2004). Hayes, Wilson, Gifford, Follette,
and Strosahl (1996) noted that psychological
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difficulties can be developed and maintained
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when individuals become experientially
avoidant, defined as an individuals efforts to
change the form, frequency, or intensity of aver-
sive internal experiences. Literature suggests
that avoidance of internal and external stimuli
associated with the traumatic experience may
play an important role in trauma-related symp-
toms (Walser & Hayes, 2006). Use of avoidance
strategies cannot only result in increases of
those avoided experiences, but can also prevent
one from responding to their experiences in
psychologically flexible way (Hayes, Strosahl,
& Wilson, 2012). When trauma survivors con-
tinuously engage in repetitive, abstract thinking
(e.g., rumination and worry), which can be con-
ceptualized as a form of experiential avoidance,
recovery from exposure to traumatic events may
be disrupted (Walser & Hayes, 2006). We ex-
amined two aspects of experiential avoidance in
relation to trauma symptomatology: rumination
and mindfulness. In this model, rumination was
conceptualized as a cognitive pattern that me-
diates trauma-related symptoms. Conversely,
mindfulness was proposed to negatively corre-
late with ruminative tendencies, which in turn
would be linked to lower levels of trauma-
related symptoms.
Rumination
Rumination is defined as repetitive and self-
focused thinking about negative past events,
their causes, consequences, and ensuing emo-
tional experiences (Nolen-Hoeksema, Wisco, &
Lyubomirsky, 2008). Rumination has been sug-
gested to interfere with the ability to respond
flexibly to the current moment and to engage in
valued life behaviors (Hayes et al., 2012). Al-
though enhancing a sense of control and secu-
rity in the short term, rumination may disrupt
emotional engagement in trauma-related mem-
ories, thoughts, and feelings, which are neces-
sary for recovery from trauma (Foa & Kozak,
1986; Walser & Hayes, 2006). Prior researchers
have found that rumination accounts for a
significant amount of variance in trauma
symptoms among ambulance service workers
(Clohessy & Ehlers, 1999) and motor-vehicle-
accident survivors (Ehlers, Mayou, & Bryant,
1998). These findings were replicated in longi-
tudinal studies on assault survivors (Michael,
Halligan, Clark, & Ehlers, 2007) and traffic-
accident survivors (Murray, Ehlers, & Mayou,
2002).
Mindfulness
Mindfulness has been described as paying
attention in a particular way: on purpose, in the
present moment, and nonjudgmentally (Kabat-
Zinn, 1994, p. 4). Segal, Williams, and Teasdale
(2002) proposed that mindfulness cultivates
awareness of ones mental state and shifts ones
attention from ruminative thought patterns to
the present moment, which may allow for more
flexible responding in a given context. Consis-
tent with the theory, Thompson and Waltz
(2010) found that mindfulness was negatively
correlated with the severity of trauma-related
symptoms in a nonclinical college sample. In a
study of veterans diagnosed with PTSD (Kear-
ney, McDermott, Malte, Martinez, & Simpson,
2012), an 8-week mindfulness-based stress-
reduction (MBSR) program demonstrated a
large decrease in symptoms of trauma and de-
pression and an increase in quality of life at
2-month and 6-month follow-ups. Further sup-
port can be found in Bernstein, Tanay, and
Vujanovic, 2011, a study reporting that mind-
fulness attention and awareness predicted sever-
ity of trauma symptomatology beyond the ef-
fects of the number of trauma types among adult
smokers. However, to our best knowledge, few
publications can be found in the literature that
report the testing of a model that includes mind-
fulness, rumination, and multiple types of trau-
matic experiences.
Exposure to Multiple Types of Trauma
Prior research suggests that the vast majority
of college students have experienced traumatic
events in their lifetimes (for review, see Frazier
et al., 2009). In a large sample of college stu-
dents, Frazier et al. (2009) found that 85% of
students reported lifetime exposure to traumatic
 RUMINATION, MINDFULNESS, AND TRAUMA
events and 21% of students reported experienc-
ing a traumatic event over the past 2 months.
This is consistent with the previous investiga-
tion in a large community sample demonstrat-
ing that age-specific risk of trauma exposure
was the highest at ages 16 to 20 years, followed
by the 21- to 25-year-old age group (Breslau et
al., 1998). These findings suggest that college
students may be at an increased risk for expo-
sure to traumatic experiences.
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A number of studies have shown that expo-
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sure to multiple types of traumatic events pre-
dicts elevated trauma-specific symptoms and
psychological distress (Briere, Kaltman, &
Green, 2008; Cloitre et al., 2009; Follette, Po-
lusny, Bechtle, & Naugle, 1996). In an early
study of cumulative trauma, exposure to multi-
ple types of victimization experiences was as-
sociated with higher levels of trauma-related
symptoms such as anxiety, depression, sexual
problems, and sleep disturbances (Follette et al.,
1996). Although it did provide a framework for
exploring this research area, Follette et als
study did not encompass a broader range of
stressor types than sexual assault and partner
abuse and did not investigate specific processes
that might influence the relationship between
trauma exposure and trauma symptomatology.
Briere et al. (2008) assessed the history of
various types of childhood traumatic experi-
ences (e.g., physical and sexual assault, life-
threatening accident, and armed robbery or
mugging) among female college students. The
findings indicated that the number of endorsed
childhood trauma types predicted symptom
complexity as measured by the number of clin-
ically elevated scales on the Trauma Symptom
Inventory (TSI; Brier, 1995). Although the
study demonstrated that multiple types of trau-
matic experiences had a cumulative effect, the
sample in this study was limited to women
reporting childhood trauma. Thus, our knowl-
edge related to trauma outcomes would benefit
from research using a sample of both men and
women who have experienced a wider range of
traumatic incidents, including other types of
interpersonal and noninterpersonal trauma.
The Present Study
For the present study, we had three primary
goals. First, we aimed to test whether exposure
to multiple types of trauma has a cumulative
397
effect on college students who have experienced
a wide range of traumatic events. We hypothe-
sized that a higher number of trauma types
would predict greater current trauma symptoms
and psychological distress. Second, empirical
studies have suggested that traumatic experi-
ence may increase the frequency of rumination
(Michael et al., 2007) and that rumination pre-
dicts trauma symptomatology (Murray et al.,
2002). Thus, we hypothesized that rumination is
a mechanism that would mediate the relation-
ship between the number of trauma types and
both trauma symptomatology and psychological
distress. Third, we investigated how mindful-
ness would impact the effect of rumination on
trauma outcomes. Thus, we hypothesized that
higher levels of mindfulness would predict
lower levels of rumination, which in turn would
negatively correlate with trauma symptoms and
psychological distress.
Method
Participants
One hundred sixty-four undergraduate students
(100 women, 64 men) from a midsize western
university in the United States participated in this
study. Participants were 65% Caucasian, 12%
Hispanic, 10% Asian American, 9% African
American, 1% Native American or Pacific Is-
lander, and 3% mixed or other. Ages ranged from
19 to 59 years (M 23.10, SD 6.21). All
participants were recruited via an online subject
pool and participated online, independently, in
exchange for extra course credit. Alternatives for
extra credit were available in accordance with the
university internal review boards policy.
Materials
Stressful Life Events Screening Question-
naireModified (SLESQ). The modified ver-
sion of the SLESQ (Goodman, Corcoran,
Turner, Yuan, & Green, 1998) is a 9-item self-
report instrument to assess lifetime exposure to
major traumatic events (e.g., life-threatening ac-
cident and sexual assault) as defined by the
Diagnostic and Statistical Manual of Mental
Disorders (4th ed., text rev.; DSMIVTR;
American Psychiatric Association, 2000). Each
of the nine items has yes or no response choices,
with yes indicating that participants have expe-
 398 IM AND FOLLETTE
rienced a particular type of event at least once.
To create a multiple trauma-exposure score, we
summed the number of endorsed trauma types,
with possible total scores ranging from 0 to 9.
The SLESQ has been shown to demonstrate
good testretest reliability ( .73; Goodman
et al., 1998), and it has been used in nonclinical
samples of college students (Elhai et al., 2012).
In assessing multiple trauma exposure, we
considered including other indicators (e.g.,
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number of episodes, duration, and age of on-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
set). However, these indicators were not suit-
able to assess a broader range of traumatic
experiences. For example, frequency can be
used to more precisely measure exposure to
temporally isolated events (e.g., motor-
vehicle accident), whereas duration may be a
better indicator of exposure to recurring or
ongoing traumatic experiences (e.g., child
emotional abuse). Given the limits of other
indicators mentioned above, we chose the
number of trauma types as our index of mul-
tiple trauma exposure.
Five Facets Mindfulness Questionnaire
(FFMQ). The FFMQ (Baer, Smith, Hop-
kins, Krietemeyer, & Toney, 2006) is a 39-
item self-report instrument composed of five
subscales, including Observing, Describing,
Acting With Awareness, Nonjudging of
Ones Experience, and Nonreactivity to Ones
Experience. The instrument was rated on a
5-point Likert-type scale ranging from 1
(never or very rarely true) to 5 (very often or
always true). Mindfulness was assessed using
the summed total score of all items, ranging
from 39 to 195, with higher scores indicating
greater mindfulness. The FFMQ has been
found to have good internal consistency in a
nonmeditating undergraduate sample (
.85, and .88 in the present sample) (de Bruin,
Topper, Muskens, Bgels, & Kamphuis,
2012).
Ruminative Response Scale (RRS). The
RRS (Nolen-Hoeksema & Morrow, 1991)
consists of 22 items that assess repetitive,
self-focused thought processes about the
meanings, causes, and consequences of ones
negative affect (e.g., Think why I always
react this way? and Think about how alone
you feel). The items were rated on a 4-point
Likert scale ranging from 1 (almost never) to
4 (almost always), and the item scores were
summed to yield a total score of 22 to 88, with
higher scores indicating greater rumination.
The RRS has shown good internal consis-
tency ( .90, and .94 in the present sample)
and testretest reliability (r .67) (Treynor,
Gonzalez, & Nolen-Hoeksema, 2003).
PTSD ChecklistCivilian Version
(PCL-C). The PCL-C (Weathers, Litz, Her-
man, Huska, & Keane, 1993) measures the
severity of trauma-related symptoms, includ-
ing avoidance, reexperiencing, and hyper-
arousal. The PCL-C consists of 17 self-report
items (e.g., repeated, disturbing memories,
thoughts, or images of a stressful experience
from the past and avoid activities or situa-
tions because they remind you of a stressful
experience from the past?) rated on a 5-point
Likert scale ranging from 1 (not at all) to 5
(extremely). Possible scores range from 17 to
85, with higher scores indicating worse
trauma symptoms. However, a structured in-
terview is warranted if a diagnosis should be
made. The PCL-C has been validated using
college samples and has shown high internal
consistency ( .94, and .89 in the present
sample) and testretest reliability (r .92)
(Ruggiero, Del Ben, Scotti, & Rabalais,
2003). At the time of this study, the PTSD
Checklist 5 (PCL-5) had not yet been re-
leased.
Brief Symptom Inventory (BSI). The BSI
(Derogatis, 1993) is a self-report measure of psy-
chological distress. The BSI consists of 53 items
that are rated on a 5-point Likert scale from 0 (not
at all) to 4 (extremely). The instrument assesses
nine symptom dimensions: Somatization, Obses-
siveCompulsive, Interpersonal Sensitivity, De-
pression, Anxiety, Hostility, Phobic Anxiety, Par-
anoid Ideation, and Psychoticism. The items
include nervousness or shakiness inside, trou-
ble remembering things, poor appetite, and
feeling lonely. We calculated the General Se-
verity Index of the BSI (BSI-GSI) score by aver-
aging all item scores, with higher scores indicating
greater psychological distress. The BSI has been
used in a wide range of settings and populations,
including college students (Cochran & Hale,
1985). The BSI-GSI has been found to have good
psychometric properties, with internal consistency
ranging from .71 to.85 (.96 in the present sample)
and testretest reliability ranging from .68 to.91
(Derogatis & Melisaratos, 1983).
 RUMINATION, MINDFULNESS, AND TRAUMA
Results
Preliminary Data Analyses
The data were checked for accuracy and eval-
uated with regard to the basic assumptions nec-
essary for ANOVA and mediation analyses.
The skewness and kurtosis values (skewness
|1.15|, kurtosis |1.03|) were within an accept-
able range (Kline, 2011). Variables were
screened for univariate outliers with z scores
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3 and multivariate outliers with Mahalanobis
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distances exceeding the critical value (2
20.52, p .001; Tabachnick & Fidell, 2013).
Of the 164 participants, there were five cases of
univariate outliers (3.0%) and two cases of mul-
tivariate outliers (1.2%), leaving a final sample
of 157 participants. Four observations (0.02%)
were found to be missing, and missing values
were replaced using person-mean imputation
(Hawthorne, Hawthorne, & Elliott, 2005). Par-
allel analyses were conducted with and without
missing values, and no meaningful differences
were found. Thus, the results with the imputed
missing data are reported here.
Exposure to Multiple Trauma Types
Table 1 presents means, standard deviations,
and Pearson r correlation coefficients for all
study variables. Participants reported experienc-
ing the following trauma types: witnessing
someone being killed, seriously injured, or sex-
ually or physically assaulted (n 32, 20.4%),
Table 1
Summary of Correlations, Means, and Standard
Deviations for Scores on the Untransformed Study
Variables (N 157)
Variabless 1 2 3 4 M SD
1. SLESQ 1.05 1.18
2. RRS .26 41.61 11.79
3. FFMQ .13 .51 132.32 17.68
4. PCL-C .26 .74 .45 32.92 11.39 significantly higher in their psychological dis-
5. BSI-GSI .32 .73 .44 .75 .59 .44 tress, as measured by the BSI-GSI, (Deroga-
Note. SLESQ Stressful Life Events Screening Ques-
tionnaire (number of trauma types); RRS Ruminative
Response Scale; FFMQ Five Facets Mindfulness Ques-
tionnaire; PCL-C Posttraumatic Stress Disorder Check-
listCivilian (trauma symptoms); BSI-GSI Brief Symp-
tom InventoryGeneral Severity Index (psychological
distress).
p .01. p .001. SD 0.37; p .005, d 0.90).
399
attempted rape/unwanted sexual contact (n
29, 18.5%), adult physical assault or abuse (n
18, 15.5%), a life-threatening accident (n 24,
15.3%), child physical assault or abuse (n 22,
14.0%), rape (n 16, 10.2%), being threatened
with a weapon (n 13, 8.3%), physical assault
involving robbery or mugging (n 8, 5.1%), or
being seriously injured or in a life-threatening
situation (n 3, 1.9%).
Participants responses to the SLESQ (Good-
man et al., 1998) were categorized into four
groups, depending on the number of trauma
types endorsed: no traumatic event (n 64),
one type of trauma (n 51), two types of
trauma (n 22), and three or more types of
trauma (n 20). We combined individuals re-
porting three or more types of trauma into a
single category because such a procedure en-
sured comparability with previous studies using
similar chunking strategies (Green et al., 2000),
it addressed a possible ceiling effect on outcome
measures, and allowed for the satisfaction of the
homogeneity assumption of ANOVA.
One-way between-group ANOVAs were
conducted to explore the effect of exposure to
multiple trauma types on trauma symptoms
and psychological distress. Results showed
that the number of trauma types experienced
was associated with trauma symptomatology,
F(3, 153) 4.85, p .003, 2p .09, and
psychological distress, F(3, 153) 8.51, p
.001, 2p .14. As shown in Figure 1A,
Tukey-adjusted post hoc comparisons indi-
cated that individuals experiencing three or
more trauma types (M 41.10, SD 12.72)
were significantly higher in their trauma
symptoms, as measured by the PCL-C
(Weathers et al., 1993), than those with zero
trauma (M 30.36, SD 10.36; p .001,
d 0.93) and those with one trauma type
(M 32.88, SD 11.43; p .027, d
0.68). Likewise, those reporting three or more
trauma types (M 1.02, SD 0.58) were
tis, 1993) than all other groups (see Figure
1B). Specifically, they had higher psycholog-
ical distress than those with zero trauma (M
0.48, SD 0.36; p .001, d 1.11), one
trauma type (M 0.56, SD 0.42; p .001,
d 0.89), and two trauma types (M 0.58,
 400 IM AND FOLLETTE

A
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Figure 1. A (top) and B (bottom): Trauma symptoms and psychological distress by number
of trauma types. PCL-C trauma symptoms, BSI-GSI psychological distress. Error bars
represent the standard errors of the observed means. p .05, p .01, p .001 using
the Tukeys HSD test.

Mediation Effects of Rumination on macro, a nonparametric bootstrap-resampling

Trauma Symptomatology
We tested two mediation models in which
two independent predictors, number of en-
dorsed trauma types and mindfulness, pre-
dicted trauma symptoms and psychological
distress through rumination. Indirect effects
were evaluated using the SPSS MEDIATE
method developed by Hayes and Preacher
(2014). Compared with other mediational ap-
proaches (e.g., Hierarchical Linear Model-
ing), the MEDIATE macro with bootstrap-
ping has the following methodological
advantages: It tests multiple independent vari-
ables in a single mediation model, demon-
 RUMINATION, MINDFULNESS, AND TRAUMA
strates higher power and lower Type-I error
rates in small samples, and requires no as-
sumptions about the sampling distribution
(MacKinnon, Lockwood, Hoffman, West, &
Sheets, 2002; Preacher & Hayes, 2004). We
report the bias-corrected 95% confidence in-
tervals for the estimates of the indirect effects
based on 10,000 bootstrap samples.
The model tested (see Figure 2) showed that
rumination mediated the relationship between
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the number of trauma types and trauma symp-
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toms. As shown in Table 2, the number of
endorsed trauma types positively correlated
with rumination, which in turn predicted greater
trauma symptoms. Results indicated that the
number of trauma types had a significant total
effect on trauma symptomatology, cp1 path co-
efficient 3.07, SE 0.66, p .001. In
addition, the indirect effect was significant for
trauma symptomatology, ap1 bp path coeffi-
cient 2.01, SE 0.51, 95% CI [1.10, 3.09].
The direct effect of the number of trauma types
was not significant after controlling for rumina-
tion, suggesting that the effect of the number of
trauma types on trauma symptomatology is
fully mediated through rumination.
Figure 2. Standardized regression coefficients for the mediating effects of rumination on
trauma symptoms. Solid lines represent total effect, and dashed lines represent direct effect.
p .05, p .001.
401
As predicted, the link between mindfulness
and trauma symptoms was mediated by rumi-
nation. Higher mindfulness predicted signifi-
cantly lower rumination, which in turn was as-
sociated with lower levels of trauma
symptomatology. Both total and indirect effects
of mindfulness on trauma-related symptomatol-
ogy were significant for trauma symptoms, cp2
path coefficient 0.31, SE 0.04, p .001,
and, ap2 bp path coefficient 0.23, SE
0.03, 95% CI [0.30, 0.16], respectively. A
significant direct effect of mindfulness on
trauma symptoms was observed when control-
ling for rumination, suggesting that the effect of
mindfulness on trauma symptoms is partially
mediated through rumination. An omnibus test
found that the test model accounted for 56% of
the variance in trauma symptoms.
Mediation Effect of Rumination on
Psychological Distress
Consistent with our hypotheses, results
showed that rumination mediated the relation-
ship between the number of trauma types and
psychological distress. A higher number of
trauma types experienced was associated with
 402 IM AND FOLLETTE

Table 2
Mediation Effects of Number of Trauma Types and Mindfulness by Rumination (N 157)
Unstandardized Standardized
Model (DV: PCL-C) estimate SE estimate t p
Model without mediator
Intercept 71.21 5.80 .01 12.27 .001
SLESQ PCL-C (cp1) 3.07 .66 .36 4.68 .001
FFMQ PCL-C (cp2) .31 .04 .46 7.16 .001
2
RY,X .30
Model with mediator
.01
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Intercept 17.46 7.33 2.38 .018

SLESQ RRS (ap1) 3.25 .64 .38 5.04 .001
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FFMQ RRS (ap2) .37 .04 .54 8.57 .001

RRS PCL-C (bp) .62 .07 .62 9.45 .001
SLESQ PCL-C (cp1) 1.06 .56 .12 1.88 .062
FFMQ PCL-C (cp2) .09 .04 .13 2.02 .045
Indirect effect (ap1 bp) 2.01 .51 95% CI [1.10, 3.09]
Indirect effect (ap2 bp) .23 .03 95% CI [.30, .16]
2
RM,X .37
2
RY,MX .56
Unstandardized Standardized
Model (DV: BSI-GSI) estimate SE estimate t p
Model without mediator
Intercept 2.08 .22 .02 9.49 .001
SLESQ BSI (cb1) .14 .02 .43 5.85 .001
FFMQ BSI (cb2) .01 .01 .47 7.49 .001
2
RY,X .34
Model with mediator
Intercept .10 .28 .02 .35 .724
SLESQ RRS (ab1) 3.25 .64 .38 5.04 .001
FFMQ RRS (ab2) .37 .04 .54 8.57 .001
RRS BSI (bb) .02 .01 .58 9.09 .001
SLESQ BSI (cb1) .07 .02 .21 3.28 .001
FFMQ BSI (cb2) .01 .01 .15 2.46 .015
Indirect effect (ab1 b) .07 .02 95% CI [.04, .11]
Indirect effect (ab2 b) .01 .01 95% CI [.01, .01]
2
RM,X .37
2
RY,MX .57
Note. SLESQ Stressful Life Events Screening Questionnaire (number of trauma types); RRS Ruminative Response
Scale; FFMQ Five Facets Mindfulness Questionnaire; PCL-C Posttraumatic Stress Disorder ChecklistCivilian
(trauma symptoms); BSI-GSI Brief Symptom InventoryGeneral Severity Index (psychological distress). The 95% CIs
were obtained by the bias-corrected bootstrap with 10,000 resamples.

greater rumination, which in turn predicted
higher levels of psychological distress. The
number of trauma types showed a significant
total effect, cb1 path coefficient 0.14, SE
0.02, p .001, and a significant indirect effect,
ab1 bb path coefficient 0.07, SE 0.02,
95% CI [0.04, 0.11], on psychological distress.
Controlling for rumination, the direct effect of
the number of trauma types was not significant,
indicating that the link between the number of
trauma types and psychological distress is fully
mediated through rumination.
Furthermore, rumination mediated the rela-
tionship between mindfulness and psychologi-
cal distress. Mindfulness was negatively asso-
ciated with rumination, which in turn predicted
higher psychological distress. Both total and
indirect effects of mindfulness were significant
for psychological distress, cb2 path coeffi-
cient 0.01, SE 0.01, p .001, and ab2
bb path coefficient 0.01, SE 0.01, 95%
CI [0.01, 0.01], respectively. The direct ef-
fect of mindfulness continued to be significant
after controlling for rumination, suggesting that
 RUMINATION, MINDFULNESS, AND TRAUMA
the effect of mindfulness on psychological dis-
tress is partially mediated through rumination.
The tested model accounted for 57% of the
variance in psychological distress.
Discussion
The current study evaluated two important
constructs that were hypothesized to explain the
relationship between the number of types of
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
traumatic experiences and trauma-related out-
This document is copyrighted by the American Psychological Association or one of its allied publishers.
comes. Consistent with previous studies (Fol-
lette et al., 1996; Green et al., 2000), the results
showed that individuals experiencing a greater
number of trauma types reported higher levels
of trauma-related symptoms and psychological
distress. It may be that experiencing additional
types of traumatic events after an initial expo-
sure to trauma exacerbates preexisting posttrau-
matic symptomatology (Follette & Vijay,
2008). Our findings provide additional support
for the cumulative effect of multiple types of
trauma exposure across a broad range of trauma
types.
Our data also provide support for the hypoth-
esis that the greater number of trauma types
participants experienced, the more likely they
were to engage in rumination, which in turn
predicted higher trauma symptomatology and
psychological distress. These findings are con-
sistent with previous research suggesting that
rumination is a maintaining factor of trauma-
related symptoms (Ehring, Frank, & Ehlers,
2008). Trauma survivors may repeatedly think
about the causes, consequences, and implica-
tions of trauma because such verbal conceptual
thinking serves to avoid aversive feelings,
thoughts, and memories associated with trauma
and to reduce physiological arousal in the short
term (Walser & Hayes, 2006). Despite possibly
providing some temporary relief, this avoidance
strategy interferes with constructive problem
solving and emotional processing of the trau-
matic experience that is necessary for recovery
from trauma (Foa & Kozak, 1986; Watkins,
Moberly, & Moulds, 2008).
We also found that mindfulness negatively
correlated with trauma symptomatology and
psychological distress, and this relationship was
mediated through rumination. Specifically, in-
dividuals with higher mindfulness were less
likely to engage in ruminative thinking, which
in turn was linked to lower levels of trauma-
403
related symptoms. This finding is consistent
with the previous study demonstrating that
mindfulness-based cognitive therapy (MBCT)
was associated with improved trauma symp-
toms and reduced trauma-related cognitions
(King et al., 2013). Mindfulness can facilitate
nonjudgmental awareness and acceptance of
present subjective experiences, thus leading to a
decrease in rumination while promoting psy-
chological flexibility (Walser & Hayes, 2006).
In other words, increased mindfulness may
change how trauma survivors relate to their
internal experiences and reduce their need to
avoid unwanted feelings, thoughts, and memo-
ries associated with trauma.
It is worth noting that 30 participants (19.1%)
received scores of 44 and above on the PCL-C
(Weathers et al., 1993), which has been sug-
gested as the clinical cutoff for college popula-
tions (Ruggiero et al., 2003). In other words, the
majority of the participants with trauma expo-
sure might not meet the full diagnostic criteria
for PTSD. Nevertheless, the mediational effects
of rumination and mindfulness did not interact
with trauma symptomatology. This indicates the
importance of further investigation into the pop-
ulation who do not meet the diagnostic criteria
for PTSD, but still experience trauma-related
symptoms. In addition, we found that the no-
trauma group had relatively high scores on the
PCL-C (M 30.36). However, Shapinsky,
Rapport, Henderson, & Axelrod (2005) found
that the PCL-C was sensitive to nontraumatic
stressors and general distress among college
students, and the mean PCL-C score (M 30.0)
for their nontreatment-seeking undergraduate
sample was comparable to that of the no-trauma
group in the current study.
Limitations
There are three limitations of this study that
are important to note. First, although the results
provide support for the mediating effects of
rumination on trauma outcomes, cross-sectional
data do not permit the determination of the
causal directions among the study variables.
One may argue that trauma symptoms and psy-
chological distress may increase rumination in
individuals with exposure to multiple trauma
types. It is also possible that rumination and
trauma symptoms exacerbate each other in a
reciprocal way. To establish firm causal direc-
 404 IM AND FOLLETTE
tions among these factors, a longitudinal study
that follows recent trauma survivors or an out-
come study targeting rumination is a logical
next step for future research.
Second, while participants were instructed to
rate on the PCL-C (Weathers et al., 1993) in
relation to stressful events, responses were not
anchored to the traumatic events that partici-
pants identified. It is possible that participants
responded to the items on the PCL-C based on
This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
their experiences with non-DSM-criteria (APA,
This document is copyrighted by the American Psychological Association or one of its allied publishers.
2000) events. This speculation gains support
from the observation that the mean PCL-C score
for the no-trauma group was relatively high
(M 30.36). To gauge the influence of this
limitation on our findings, we reran the media-
tion analyses without the no-trauma group. The
test statistics and estimates were found to be
either comparable or stronger when the no-
trauma group was removed. Despite this result,
our findings must be interpreted with some cau-
tion.
Third, the results of the current study may be
limited in generalizability. Literature suggests
that the age group of college students is at
greater risk for experiencing traumatic events
(Breslau et al., 1998), and understanding trauma
in college populations is an important area for
research. However, the sample in the current
study consisted of nontreatment-seeking college
students, and most of the participants with
trauma exposure did not report severe clinical
symptoms. Furthermore, data collection relied
upon retrospective self-reports of trauma. Thus,
caution needs to be exercised in interpreting and
generalizing the findings to other populations.
While these are important issues to note, they
also provide important suggestions for future
research in this area.
Clinical Implications
Despite several limitations, the current study
resulted in important clinical implications for
trauma intervention. It is noteworthy that rumi-
nation plays a mediating role in trauma out-
comes. The tested mediation models accounted
for over 50% of the variance in trauma symp-
toms and psychological distress. In fact, rumi-
nation mediated about 60% of the total effects
on trauma outcomes. These findings point to the
importance of developing psychological inter-
ventions that target rumination. Several thera-
pies, such as rumination-focused cognitive-
behavioral therapy (RF-CBT), MBCT, and
acceptance and commitment therapy (ACT),
have been shown to reduce rumination among
depressed individuals (Kingston, Dooley, Bates,
Lawlor, & Malone, 2007; Tamannaeifar,
Gharraee, Birashk, & Habibi, 2014; Watkins et
al., 2011). However, further research is needed
to evaluate the efficacy of interventions target-
ing rumination in trauma survivors.
Moreover, exposure to multiple types of trau-
matic events may exacerbate preexisting trauma
symptoms and psychological distress. College
students are at high risk for exposure to trau-
matic events, indicating the importance of ad-
dressing the mental health-care needs for col-
lege students experiencing traumatic events
(Frazier et al., 2009). Clinicians need to exam-
ine the lifetime history of trauma exposure and
their cumulative impact more broadly, instead
of solely focusing on the most traumatic and
recent event. A comprehensive assessment may
allow clinicians to identify mechanisms that are
associated with maintaining trauma symptom-
atology. Considering the cumulative effect of
multiple types of traumatic experiences, psy-
chological interventions may need to be modi-
fied for individuals who report having experi-
enced multiple types of trauma. Moreover, our
research provides guidance for clinicians in en-
hancing treatments for individuals who have
been exposed to repeated traumatic events. Al-
though we already have important evidence on
therapies for trauma, this research has provided
a foundation for targeting underlying mecha-
nisms that may explain the long-term impact of
exposure to multiple types of trauma.
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Received October 15, 2015
Revision received July 25, 2016
Accepted September 16, 2016